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Background: The feasibility of video-assisted retroperitoneal debridement (VARD) for infected pancreatic walled-off necrosis is established. We provide prospective data on the safety and efficacy of VARD., Design: Multicenter, prospective, single-arm phase 2 study., Setting: Six academic medical centers., Patients: We evaluated 40 patients with pancreatic necrosis who had infection determined using Gram stain or culture., Interventions: Percutaneous drains were placed at enrollment, and computed tomographic scans were repeated at 10 days. Patients who had more than a 75% reduction in collection size were treated with drains. Other patients were treated with VARD. Crossover to open surgery was performed for technical reasons and/or according to surgeon judgment., Main Outcome Measures: Efficacy (ie, successful VARD treatment without crossover to open surgery or death) and safety (based on mortality and complication rates). Patients received follow-up care for 6 months., Results: We enrolled 40 patients (24 men and 16 women) during a 51-month period. Median age was 53 years (range, 32-82 years). Mean (SD) Acute Physiology and Chronic Health Evaluation II score at enrollment was 8.0 (5.1), and median computed tomography severity index score was 8. Of the 40 patients, 24 (60%) were treated with minimally invasive intervention (drains with or without VARD). Nine patients (23%) did not require surgery (drains only). For 31 surgical patients, VARD was possible in 60% of patients. Most patients (81%) required 1 operation. In-hospital 30-day mortality was 2.5% (intent-to-treat). Bleeding complications occurred in 7.5% of patients; enteric fistulas occurred in 17.5%., Conclusions: This prospective cohort study supports the safety and efficacy of VARD for infected pancreatic walled-off necrosis. Of the patients, 85% were eligible for a minimally invasive approach. We were able to use VARD in 60% of surgical patients. The low mortality and complication rates compare favorably with open debridement. An unexpected finding was that a reduction in collection size of 75% according to the results of computed tomographic scans at 10 to 14 days predicted the success of percutaneous drainage alone.

Purpose: To explore the use of breath-hold and navigator-gated noncontrast Steady State Free Precession (SSFP) MR angiography (MRA) protocols for the evaluation of renal artery stenosis (RAS)., Materials and Methods: Twenty patients referred to rule out RAS were imaged using two breath-hold and one navigator-gated SSFP MRA sequences. All patients underwent contrast-enhanced MRA (CE-MRA). Two radiologists evaluated all sequences both qualitatively (blur, artifacts, reader confidence) and quantitatively (maximum stenosis). Using CE-MRA as truth, a receiver operating characteristics (ROC) curve was generated and a statistical analysis of navigator-gated SSFP (Nav SSFP) was performed., Results: Seven patients had >50% renal artery stenosis by CE-MRA. Nav SSFP performed significantly better than either breath-hold SSFP technique in terms of blur, artifacts, and reader confidence. Using a 50% threshold for stenosis, sensitivity for detecting RAS was 100%, with a specificity of 85% and a negative predictive value of 100%. The average mean stenosis difference between Nav SSFP and CE-MRA was 9 +/- 9%., Conclusion: Nav SSFP outperformed breath-hold SSFP in measures of image quality and reader confidence. Sensitivity and negative predictive value for detecting RAS with Nav SSFP was perfect, with an acceptable specificity of 85%. This suggests further study is warranted to evaluate Nav SSFP as a noncontrast screening technique for renal artery stenosis., ((c) 2007 Wiley-Liss, Inc.)

Objective: The purpose of our study was to determine how well unenhanced navigator-gated steady-state free precession (Nav SSFP) MR angiography (MRA) performs as a screening test for the detection of renal artery stenosis., Subjects and Methods: Forty patients referred to rule out renal artery stenosis were imaged using an optimized Nav SSFP MRA sequence before conventional contrast-enhanced MRA (CE-MRA). Two radiologists evaluated Nav SSFP for maximum stenosis measurement, and comparison was made with CE-MRA results., Results: Fifteen of the 40 patients had greater than 50% renal artery stenosis as determined on CE-MRA. Sensitivity for detecting renal artery stenosis with Nav SSFP was 100%; specificity, 84%; negative predictive value, 100%; and positive predictive value, 79%. The average mean stenosis difference between Nav SSFP and CE-MRA was 10% +/- 9%., Conclusion: Sensitivity and negative predictive value for the detection of renal artery stenosis using Nav SSFP were perfect, with an acceptable specificity of 84%. This suggests Nav SSFP is a promising technique for simple unenhanced screening for the detection of renal artery stenosis.

Goals: To determine whether increased pulmonary artery pressure (PAP) following transjugular intrahepatic portosystemic shunting (TIPSS) results in short-term mortality or cardiorespiratory complications., Background: TIPSS is frequently performed for complications of cirrhosis. PAP increases following TIPSS; however consequences of this phenomenon are unknown., Study: Demographics, disease severity and etiology were recorded among patients undergoing TIPSS. PAP before and following TIPSS were measured and the relationship between PAP before and after TIPSS, and subsequent cardiorespiratory complications and mortality was examined., Results: Thirty-one patients were enrolled (mean age 53 years, 74% men, 55% Child-Pugh class C cirrhosis). TIPSS was performed for variceal bleeding in 84% of cases. Ten patients (32%) died 5-20 days following TIPSS. PAP increased significantly following TIPSS (mean 20.8 mm Hg pre-TIPSS (95% CI 18.2-23.4) to 26.9 mm Hg post-TIPSS (95% CI 24.2-29.6, P = 0.0016). Congestive heart failure developed in 4 patients (13%), sepsis in 4 (13%), and ARDS in 8 (26%). Increased PAP following TIPSS was not associated with early mortality (P = 0.13), CHF (P = 0.31), or ARDS (P = 0.43). ARDS was the only significant predictor of short-term mortality following TIPSS (OR 18.7, P = 0.02 (95% CI: 1.5-232)., Conclusion: PAP increases after TIPSS and cardiorespiratory complications are common, yet unrelated to increased PAP. ARDS is independently associated with increased risk of mortality after TIPSS.

Purpose: The safety and efficacy of percutaneous transluminal intervention for renal artery stenosis is improving. This study evaluates the immediate and long-term anatomic and functional outcomes of percutaneous transluminal angioplasty and stenting for atherosclerotic renal artery stenosis in a Veterans Affairs population., Methods: We performed a retrospective analysis of records from patients who underwent renal artery angioplasty with or without stenting at the Veterans Affairs Puget Sound Health Care System between January 1990 and June 1999. Indications for intervention included hypertension (78%) and rising serum creatinine (78%). Seventy-six patients (74 men, average age of 67 years, range 42-83 years) underwent 88 attempted interventions. Seventy-two percent of contralateral kidneys had significant disease (47% had a >60% stenosis; 16% were nonfunctioning or absent)., Results: Of the 88 planned interventions, 86 were successfully performed with placement of 46 stents (52%). Technical success (defined by <30% residual stenosis) was achieved in 78 vessels (89%). The procedure-related complication rate was 5%. Patient mortality by life table analysis was 49% at 5 years. Assisted primary patency rate at 5 years was 100%. Primary and secondary restenosis rates were 37% +/- 8% and 31% +/- 8% at 5 years, respectively. Sixty-eight percent of patients treated for hypertension demonstrated clinical benefit (improved or cured hypertension). This clinical benefit was maintained in 52% of the patients at 5 years, as measured by life table analysis. Serum creatinine was lowered or maintained in 88% of the patients, but this clinical benefit was only maintained in 25% of patients at 5 years., Conclusions: Transluminal intervention for clinically symptomatic atherosclerotic renal artery stenosis is technically successful and safe. There are excellent assisted-patency and low restenosis rates. There is immediate clinical benefit for most patients, as evidenced by improved control of hypertension and preservation of renal function. However, within 5 years the benefit is not maintained for either hypertension (50%) or renal function (20%). Therefore, although technically successful, functional outcomes after endoluminal intervention are not maintained in the long term.

This report describes the transluminal placement of a stent graft occlusion device to treat a celiac bypass graft pseudoaneurysm which was causing biliary and duodenal obstruction.

The gallbladder is traditionally regarded as an absorptive organ. There is increasing evidence that the gallbladder mucosa can have a secretory function. We studied a patient with primary sclerosing cholangitis whose gallbladder was excluded from his extrahepatic bile ducts by stricture formation. He was admitted into hospital because of cholecystitis and cholangitis and required separate drainage tubes into his gallbladder and common hepatic duct. This unique combination of drains afforded the opportunity to examine hepatic bile and gallbladder secretion. We analyzed samples for fluid volume, protein, electrolyte concentrations and biliary lipids. The simultaneous, yet separate, drainage from the gallbladder and the liver had a striking difference. The former was colorless to opalescent; the latter always golden brown. Hepatic bile flow was continuous but gallbladder drainage was variable in volume, intermittent, and occurred only after a meal. The gallbladder fluid had no bilirubin, bile salts, cholesterol, or phospholipids and had the ionic profile of an extracellular fluid. It was alkaline and contained abundant bicarbonate. We have shown that the gallbladder can secrete. In addition, these observations may also have important implications in the pathogenesis and prevention of gallbladder sludge and stones.

Purpose: The short and long-term anatomic results of percutaneous transluminal renal angioplasty (PTRA) in the treatment of atherosclerotic renovascular disease have been poorly documented because of a lack of follow-up arteriography. The purpose of this study was to evaluate the anatomic results of PTRA with serial duplex examinations., Methods: The records of 41 patients who underwent 52 primary PTRA procedures and had subsequent duplex follow-up of at least 6 months were reviewed. After PTRA, renal arteries were classified as normal, < 60% stenosis, > or = 60% stenosis, or occluded on the basis of previously validated duplex criteria., Results: The study group included 26 men and 15 women with a mean age of 65 years, who were observed for a mean interval of 34 months. Endovascular stents were placed in 12 of the 52 arteries. The initial post-PTRA renal artery stenosis classification (based on arteriography or duplex scan) was normal in 23, < 60% in 19, and > or = 60% in 10. The cumulative incidence of restenosis from normal to > or = 60% was 13% at 1 year and 19% at 2 years. The cumulative incidence of restenosis from < 60% to > or = 60% was 44% at 1 year and 55% at 2 years. The cumulative incidence of progression from > or = 60% to occlusion was 10% at 2 years. Although 83% of the 12 stented arteries and only 33% of the 40 nonstented arteries were normal immediately after PTRA, after 1 year the stented renal arteries showed a 44% restenosis rate, whereas the nonstented renal arteries showed a 18% restenosis rate (p = 0.087)., Conclusions: Restenosis after PTRA for atherosclerotic disease is relatively common and correlates with the initial anatomic result. Although PTRA with stent placement yields superior immediate technical results, the high early restenosis rate is disturbing.

Successful treatment by percutaneous catheter drainage of an acute aortic graft infection with an associated pancreatic fistula is reported. Percutaneous catheter drainage can be considered in selected patients when the risk of reoperation is deemed unacceptable or when other reasonable treatment options do not exist.

Objective: The purpose of this study was to prospectively evaluate cardiac-gated two-dimensional (2D) time-of-flight MR angiography in patients with peripheral arterial occlusive disease (PAOD)., Subjects and Methods: Twenty-three patients with PAOD were studied using cardiac-gated 2D time-of-flight MR angiography in the body coil from each patients' aortic bifurcation to the pedal arches. Blinded comparison with conventional angiograms was used to determine sensitivity, specificity, and positive and negative predictive values of this MR angiography technique. Kappa statistics were used to compare treatment plans of these patients studied with MR angiography and with conventional angiography., Results: In the aortoiliac region, MR angiography had a correlation coefficient of .89 for all degrees of narrowing. For hemodynamically significant lesions, MR angiography had an 89% sensitivity, 98% specificity, 84% positive predictive value, and 99% negative predictive value. In the femoral region, MR angiography had a correlation coefficient of .91 for all degrees of narrowing. For hemodynamically significant lesions, MR angiography had an 89% sensitivity, 98% specificity, 93% positive predictive value, and 97% negative predictive value. In the popliteal region, MR angiography had a correlation coefficient of .93 for all degrees of narrowing. For hemodynamically significant lesions, MR angiography had an 89% sensitivity, 98% specificity, 94% positive predictive value, and 95% negative predictive value. In the tibioperoneal and foot regions, MR angiography had a correlation coefficient of 88% for all degrees of narrowing. For hemodynamically significant lesions, MR angiography had an 86% sensitivity, 93% specificity, 89% positive predictive value, and 91% negative predictive value. When the treatment planning data were classified into one of four outcomes (no intervention, surgery, percutaneous angioplasty, or further diagnostic study), MR angiography and conventional angiography had excellent agreement, with a Cohen's kappa value of .78., Conclusion: Cardiac-gated 2D time-of-flight MR angiography that uses the body coil provides a useful examination for PAOD with reasonable resolution. This imaging technique is potentially more time-efficient than techniques using extremity coils.

Selective urokinase infusion into the superior mesenteric artery allowed the accurate determination of the site of small bowel bleeding in a patient with recurrent lower gastrointestinal bleeding who bled despite resective surgery and who had negative findings on four angiograms. Fibrinolytic agents are useful in rare cases in which the need for successful and accurate diagnosis outweighs the risks of reactivating the bleeding.